NRNPH

Thank you all for the input! I wish my unit could explain and talk to each other in such a supportive and learning way. Its a practice, always things to learn and a different perspective to see.

Even though it is not their attending the NP's and PA's discharge for them and have access to their notes. Its hard to tell when they will round depending on their surgical schedules and when you call in the morning, you get the same NP or the PA either way. They have access to charts and notes indicating possible discharges, etc. The NP did say they would pass onto the rounding team this information finally at the end. The only reason this is an issue because they complained they were woken up. In my mind, its 0630-ish, closer to 0700 and you are getting paid to be on call until 0730 so if someone calls, it is still your job to answer.

Quick background - we have certain patients that don't have hospitalist teams to text page because they are patients of MD's who have separate offices within the hospital so we have to call the answering service and speak with whoever is on call. Whoever is on call for the MD's (always PA's or NP's) stay at home and are on call and answer when needed by RN's. I had an elderly patient and due to some miscommunications from the MD and RN's the patients SO drove almost 2 hours to get here to pick them up. They were understandably upset when no discharge orders were in, they insisted that they were told by the MD that they would go home (they had no reason to stay. medically stable, could have discharged day before) and I told them that the MD's try to round early in the AM or as soon as their surgical schedule allows them time. This answer wasn't good enough, patient's SO stating they can't wait long and its a long drive. Understandable. 2 hour drives for elderly couples is so taxing. So since its close to 7 AM, I got on the phone NP to see if there were any notes or any indication for discharge so I could soothe the patient's irritation and anger by giving them something other than I don't know and not do anything about it. It wasn't like it was in the middle of the night. Granted, I should have talked to the CN first (I ALWAYS do before I call except this one time) but they were at report and you don't call them unless its an emergency cause they don't want interruptions. I figured its close to the morning about 0630 (day shift calls right in the morning for patients anyways for needs when its 0700) and it seems appropriate enough as they kept saying they could not wait long and needed to get back. Hospital is all about patient satisfaction to get those satisfaction scores so I took that extra step. The provider did not let me get a word in. Rude, condescending, they always talk like this to any RN that calls. They have access to patient's charts and MD's notes from their home. Didn't give me one piece of information. I explained the patient's circumstances and the miscommunications going on and in order to get the patient an answer they can be okay with so that they don't take it out on the next person or the MD. Why pass on an angry patient and make someone else deal with that blow back when you could possibly solve it. NP calls my charge mad. My charge said it was fine but that the provider did the same thing to her and would not let her get a word in and "yelled" and I filed a grievance report because this is not the first time having to deal with this NP being disrespectful. I don't mind calling out disrespectful behavior to any staff regardless of your temper. I get you're irritated from being woken up but keep the professionalism will you? All I get back from the Manager is that moving forward it is mandatory to talk with CN before contacting MD (yes already knew this but I thought I was making an okay call due to it being 0630 and the circumstance of the patient and SO). Nothing regarding MD's behavior. What is really bugging me is the fact that MD's on call get upset when they are called. In my head its the same as if I am on call. I assume I am to be called at any moment to come in and I don't get upset. They get on call pay and they are sleeping at home and get the occasional phone call (I know this because they are only MD's for my floor so they get 1 call maybe in the middle of the night for must haves). If you're on call, you're on call. You're being paid, its your job so why get upset when you are called and asked to do your job as a provider? I always try to respect the provider's time and expect them to respect that. I don't work FOR them, I work WITH them. Apparently here that's still not quite getting through. I guess being called in the AM when every MD is awake and getting ready for rounds was unacceptable and this provider got mad. The patient and SO were actually super grateful and after knowing I called to get an answer but there was nothing in any notes, they were more than willing to wait for whenever the MD rounded and now I would be passing on a happy patient to the MD rounding and the oncoming Nurse instead of a disgruntled patient and SO. Am I wrong for feeling irked? Am I wrong for being frustrated with some providers here that get upset but their job is to be on call? I'm doing my job, its time to do yours. Am I wrong for seeing it this way? Am I wrong feeling irked that my Manager didn't even address the provider's demeanor towards me and my CN?

Thank you all for your advice and input thus far! I took a lot of things from each of you and it gave me some peace after must emotional turmoil and questioning morals/ethics. I appreciate the term reality shock. I believe it is what I am going through and not burn out. I love my job. I go in no matter what and give my patients the best care I can with what I am given. It is very shocking and disheartening when you build a practice and advocate for changes to increase patient safety and quality, individual care and it feels like you receive blow back for wanting these things and working to fight for it and stand for it as a Nurse in my unit. I will be taking some time off here soon and work on some things and figure out what it is I really want and if they are reasonable and attainable. I will always be the Nurse who pushes back for my patients. I am willing to accept the mostly condescending or text book answers that are not enough answers for my patients - for now. I am well aware this is unfortunately a widely felt and known topic. Thank you all for reading, responding, supporting. I hope to hear more and take more and use them to better myself.

I like your perspective about burn out. When it comes to fault finding, 95% of my career has been spent fault finding in myself. Questioning what I could have done better and being very self critical. I just have spent the most recent portion of my career speaking up and I wouldn't say "fault finding" but more of a holding people accountable. Is it wrong to point out things that could have been avoided if people worked better together? I am the Nurse who goes to work for the patients first and relationships second. I come home every day wondering what I could have done better but I have recently begun to think that everybody who is in involved in the patient's care, is responsible for patient outcomes. I stopped taking all the blame onto myself and started to speak up (only at appropriate times - my patient's safety was put at risk, pattern of unsafe events, serious things) because I don't want it to happen to other patients and Nurses down the road. I hate that pushing for us to all grow together.. it makes me feel so.... icky for lack of a better word. I get that I am imagining a perfect health care world where everyone is accountable and things run smoothly but there's nothing wrong in trying to take small steps towards that right?

Thank you for this. You are right, why let one job make me throw away the entire career - burn out. I guess I weirdly hate to admit it and have avoided that as a possibility. The thought that I could really be experiencing burn out after a year is slightly discouraging - as a seeker of perfection, I feel I should have done better to not be in this place. You are absolutely correct. I take time off to try and push work to the back of my mind rather than truly consider the change. It honestly is a scary thought and disappointing that my first job wasn't "the one" but I'm sure everyone goes through it. I need to choose to do things to create change for the better. I will however maybe spend a day to sulk just to feel it, process it and accept it.

Some background. I've been a Nurse for a little over a year. Work nights. Like many hospitals understaffed and overworked. 6:1 ratios with high acuity patients, sometimes no CNA's or CNA's have half of a high acuity floor, act like a step down ICU with some of the patients who are not appropriate for the floor, shorted in everything - the list goes on. You can push for resources as much as you want and get nothing. 10 nurses gone in about a 18 month period for the floor and counting. I'm sure many of you know how I feel. No matter how crazy the nights were I used to love my job. Used to. As I have grown in my practice and become more confident in speaking out my concerns for my patients, contacting and pushing educators and coordinators to voice my frustrations and try to spark a change - only to walk away feeling like a total fool. For a place that "promotes" and advocates for so many things, "promotes" highly encourage learning, "state" being open minded, "push" Nurses to make a difference and want changes to occur so that we all can advance and grow in an ever changing field - when the time comes to act, they refuse to live up to their mission and values and change. They have taken my questions and concerns with disdain. As a Nurse, every patient I deal with, is a human life in my hands. The patients I take care of each shift trust me to protect them, advocate for them, be knowledgeable about them, and over all value their individual lives regardless of how many patients or other people that need care are out there. I like being thorough. I believe I am doing a disservice to my patients if I do not get a whole picture from their chart (even if it is just very basic - it would be a dream to have enough time every day to delve into each patient) in order to serve them the best for that shift. I have begun raising concerns regarding my patient's safety being put at risk. Asking questions why things are done a certain way and trying to learn and also provide feedback as a floor Nurse. Those concerns are easily dismissed and in return we are docked on items that are solely intended to raise the hospital's status and finances. I get that is what hospitals have to do but if the employees can barely keep their heads above water - the patients are the ones who really suffer from hospital issues. All cares are affected. This hospital doesn't seem to understand that or care when concerns are brought up. Like many hospitals I am sure. It feels like they focus on the *** rather than what health care should really be about. I know this could open a whole can of worms and branch into other things but this whole post is really about one thing - Do I quit? I have had it. I feel cheated. Shorted. I have moral crises everyday. I fight with myself constantly after work when I go over how a shift went. The anxiety. The stress. The tears. Work thoughts always take over. No matter where I go, what I do - even my self care getaways. I am tired of being told that my passion for this job is a "new nurse (whatever they say)" and I am devastated. Today I felt that this place robbed me of my love for this job. Its weighing so heavily on me. I have never been at such a cross roads before. I sacrificed so much to become a Nurse but this place has me truly considering leaving the career completely and make me ask "what's the point". I could apply to another hospital but my work has made me feel there is no place in the health care world that isn't different than what things are like now. I am mentally exhausted. I can never refresh. Do I quit? Do I stay? If I stay, how do I survive? Would love to hear what people who have gone through this have felt, thought, and done.

Obviously there are things we don't share in front of the patient what we don't need to be sharing but I found it odd that during shift change when I felt it was inappropriate to go into a patients room and do a full bed side report who had major short term and dementia (obviously afterwards we introduce ourselves after), I was told that's not a reason and they had us go into this confused pt's room who is barely oriented to self and do a full bedside report. Even if it was a pt who had been up all night and finally was getting some sleep in the morning and passes out right before shift change. I don't know how else to advocate that these are good reasons that a full bed side report is not done when they audit us every morning.

Sore subject. Bedside report. I don't mind it at all. The only time I don't like to do bedside report is for confused patients, dementia, impulsive patients that are fall risks that you finally calmed down and they are in a low stimulation environment and the like. For these patients I believe it to better to do report outside and then enter the room to see the patient. I feel that patients who are confused and aren't oriented would not benefit from a bed side report. I feel it could confuse them more or they make take some information you say and misinterpret things and could cause issues. I feel patients who finally have calmed down, suddenly get stimulated and worked up and start bed exiting again and I feel it does not do any good for them to hear it. I was told by a charge that these were not reasons to not do a full bedside shift report in the patients room. Just wanted some thoughts on what practices were in other hospitals. What are those reasons where a full bedside report would not be reasonable?

wait you would serve the soda or you wouldn't?

You had to have PPE to be around the pt. I always remind myself to be more mindful of my PPE pts and their immune systems.

We don't mix it. I believe the dietary unit does. But correct on the rest. I would have preferred to prepare a new bag/tubing. I didn't have one on that shift and I am sure we do.

oh no. I don't know how long its been "uncovered". It could have been during transport. It's made on the first floor then moved and stored on our floor until we end up needing to use it. So I don't know how long it's been "open". If it happened in such a short trip I would have changed the bagging and be done.

Half of me wants to say I over thought it but the other half of me said I don't know the condition of the formula regardless of it being non sterile it was open to the environment around it because nothing was covering the opening. I honestly was thinking to myself I don't want to give my pt bad formula. They were already immunocompromised, doesn't mean its ok to compromise it more.

i get that but in my head I imagined it as if you left your drink or food uncovered especially in a patient fridge that already has god knows what from nurses in and out of there from patient rooms just open to your food. That's what it is. I saw the formula as uncovered food. Just thought bacteria, uncovered food, bacteria loves the uncovered food, pt is already sick anyways, try to prevent dealing with another issue. Didn't want to "chance" it. I get that you can see it like a glass of milk but to me every decision I make effects that person's life. That's just how it feels to me still. Hence why I didn't hang it.

not worried about the tubing. worried that formula was open to it. just bacteria in general. i know its non sterile but still you wouldn't just leave a can open without a lid on it and then just use it later right?

I can see that point. I know enteric isn't a sterile procedure but if that purple cap just gets connected right to whats going into the patient any bacteria that got on that purple end is going to feed off of all that food moving through the tube.

I would love some input and bounce ideas off of anyone who is willing to give any thoughts on what they would have done in my situation. I refused to hang a feeding bag for a patient because of huge concern for infection (we searched the areas in hopes that another bag had been prepped but there were none and I would prefer to prevent possible infection rather than chance it). I am typing my thoughts out loud so I apologize if things are over simplified or all over the place. I know you all probably know this and know I don't have to over explain but its my current thought process. Thank you ahead of time. We have pumps for enteral feedings. Some are prepared by mixing formulas and putting them in refrigerated bags with the tubing required for the pump already attached. I don't know if that image helps but think of an IV bag but filled with formula and the tubing is directly attached to the IV bag with a purple adapter at the end that should have a white cap with a cover cap on it. If you hang the bag you don't get anything in the tubing - you have to prime it through the pump - but squeeze the bag with your hand and the formula moves into the tubing. Not much, but enough to tell me that the bag is open to the tubing which means its open to the formula. The bag and the tubing are non sterile and technically the formula since it is prepared and not sterile either but my focus is on the formula. I refused to hang a formula for the best interest of my patient but a lot of my co-workers don't seem to understand why I didn't do what they would do - I will explain. As a Nurse its all drilled into our heads that bacteria is everywhere, try to be as clean as possible, etc. to prevent infection. I know we have bacteria in our gut. I know that the pump set is non sterile, that the steps to connecting it to the PEG is non sterile, I get that. So I get this bag from the fridge with nothing in the tubing (normal) and head into the room which i need to wear PPE for. I hang the bag, get the tubing correctly in the pump, then grab the end of the tubing that will attach to the PEG tube so that I can prime the tubing into a container of some sort. I get to the end of the tubing to find that the purple adapter at the end with a white cap and a cover for the cap (this is the portion where you take off the cap cover and connect it to the PEG) is gone. The white portion with the cap screws on and off (which we do not do, they come already screwed on) and somehow it was gone and the purple adapter (its just the open end of the tubing with purple plastic around it so that the white part can screw on and off) was uncovered. Ok, so I have a bag with tubing that is non sterile, being transported, the white cap got lost somehow, so now the tubing is what I consider "opened." Yes, the formula is in the bag and not in the tubing and doesn't come down the tubing until you prime it - well it does if you squeeze it but not the whole way - so it wouldn't be a big deal to just place the formula into another pump bag we have and use it right? As long as the tubing is just changed out everything should be fine and not a big deal right? My Charge and some other RN's were all telling me that but I just for some reason couldn't understand why they couldn't understand so maybe I am crazy. Anyways reading those things it sounds okay right? Well in my head I kept thinking WRONG. Like felt it in my gut WRONG. Like I am still asking about it WRONG. Because be squeezing the bag and seeing it flow into the tubing shows me that the formula is "open" to the tubing. The white portion that connects to the PEG was gone who knows when and during that time I don't know what the purple "open" tube bumped into or collected sitting in the fridge that we all reach into for patients. So my thought was, bacteria moves and grows through lines right? IV lines etc. That means whatever was in contact with that purple end would moved through the tubing and up to the formula or at least come in contact with the formula because its "open." I can't just connect the white cap on from another tubing set (i'd be screwing on the bacteria at the site that is closest to the PEG site) and I can't just change the bag and the tubing because it was "open" during transport, during it being in the fridge, etc. So in my head I am thinking the formula is no good. The formula was susceptible to whatever because it wasn't closed off with the white portion. The formula is what worried me. Bacteria love formula. Even the smallest colony would have a feast with formula. I didn't trust that simply changing the bagging and tubing would change the fact that the formula technically remained open to whatever because there was nothing on the other end. Ok I apologize about this long tirade. Please, thoughts. Agree? Disagree? Thank you!